Provider Demographics
NPI:1508493248
Name:BOISSONNEAULT, MARK ANTHONY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:BOISSONNEAULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 OLD RUDNICK LANE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901
Mailing Address - Country:US
Mailing Address - Phone:302-674-9255
Mailing Address - Fax:302-674-9096
Practice Address - Street 1:22 OLD RUDNICK LANE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901
Practice Address - Country:US
Practice Address - Phone:302-674-9255
Practice Address - Fax:302-674-9096
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEE1-0010279213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000827650Medicaid